Provider Demographics
NPI:1457555823
Name:GRYTZELIUS, DEREK FLOYD (DDS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:FLOYD
Last Name:GRYTZELIUS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13750 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-2702
Mailing Address - Country:US
Mailing Address - Phone:586-247-0010
Mailing Address - Fax:586-247-4333
Practice Address - Street 1:13750 19 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-2702
Practice Address - Country:US
Practice Address - Phone:586-247-0010
Practice Address - Fax:586-247-4333
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI189701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice